Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 9 - Evidence
OTTAWA, Thursday, April 26, 2001
The Standing Senate Committee on Social Affairs, Science and
Technology met this day at 11:03 a.m. to examine the state of the
health care system in Canada.
SenatorMichael Kirby (Chairman) in the Chair.
The Chairman: Senators, I suggest we begin. We have three
witnesses this morning. We will hear them sequentially, rather
than as a panel, because they will be speaking on three different
Our first witness is Dr. Alan Bernstein, President of the
Canadian Institutes of Health Research, also known as CIHR. We
should congratulate Dr. Bernstein, as it was a year ago today that
his bill was passed. As you will recall, this committee dealt with
the bill that created the CIHR; we had extensive discussions with
many individuals, including Dr. Bernstein, as I recall.
We are delighted to have you with us.
Dr. Bernstein has distributed a handout, which includes on the
last four pages overheads, to which I presume he will referring.
Dr. Alan Bernstein, President, Canadian Institutes of
Health Research: Thank you very much for this opportunity,Mr. Chairman and honourable senators. I do appreciate this
opportunity to appear before the Standing Senate Committee on
Social Affairs, Science and Technology for your study on
Canada's health care system.
I notice that Phase 2 of the study is entitled "Future Trends,
Their Causes and Impact on Health Care Costs," and it is to that
aspect that I would like to speak to you this morning.
As Senator Kirby said, today is the anniversary of Parliament's
passing of the bill that created the CIHR. This committee was one
of midwives of the bill that created CIHR.
The Chairman: As such, we are not covered by medicare.
Dr. Bernstein: I would note that your colleague Senator Morin
is undoubtedly one of the parents of CIHR. He was, first, a
distinguished member of the Medical Research Council, the
predecessor organization of CIHR; he served on both the interim
governing council of CIHR and then the governing council of
CIHR before you stole him away to the Senate. It is our loss and
the country's gain. Of course, Senator Morin is himself a
distinguished clinician and researcher.
It would not be an understatement to state that the current
revolution in health research will be one of the drivers, if not the
single largest driver, of change in the health care system in the
next 10 to 20 years. This scientific revolution is being fueled by
our rapidly emerging understanding of the molecular basis of life,
of human biology and human disease, and the recent and ongoing
advances in genetics and genomics, together with an appreciation
that our health and susceptibility to disease is really the
summation of a complex interplay between environmental factors,
genetics and social factors. That appreciate will transform our
health care system in the next 10 to 20 years.
I have divided those changes into four areas. At the moment,
our health care system is largely reactive. We largely interact with
the health care system when we are ill. That is going to change as
a result of the genomics revolution. For example, the genes that
are involved in about 10 per cent of breast and colon cancers have
been identified. Schizophrenia and diabetes will be next. We have
the potential now, if one has a family history of those diseases, to do a DNA test and to say, "You will get breast cancer
with a 94 per cent probability in 60 years, based on genetic inherence."
There is not much we can do about breast cancer other than a
preventive mastectomy. Yet, studies have shown that many
women want to know, if they have a family history of breast
cancer, whether they have these mutations. Again, with colon
cancer the gene has been identified. We have gone from an
ignorance of that disease to now being able almost routinely, if
one has a family history, to sequence the FAP gene, which is
involved in colon cancer, and if one has the mutation, to removing
the polyps, the pre-malignant growths that emerge and prevent
that disease, which is inevitably otherwise fatal.
This is a different kind of health care. It will develop as more
and more disease genes are identified over the next few years.
It is also raising profoundly new ethical, legal and social issues
for all of us to deal with. Those new molecular insights, of course,
will also mean that we are moving from a descriptive phase of
medicine and health care to a mechanism-based description,
where we understand the basic underlying biology of disease.
That will change how we diagnose disease. It will also change
and is changing how drugs are discovered. These new therapies,
whether they are drug, gene or stem cell therapy, will be
expensive but effective. They will also, for both those reasons,
have profound impacts on Canada's health care system.
Information technology, another major driver of change, is also,
as I said in my submission to you, effectively going to
democratize the health care information highway. Anybody now
has access to the information. The clientele is going to be
knowledgeable and will want access to the latest drug or other
therapies. Of course, it will have an impact on delivering health
care to Canada's remote rural and northern regions as well.
The final driver of change will be demographics. There is a
bulge of people my age moving through the system. It will have
quite a profound impact on the health care system over the next 20 to 30 years.
It is within the context of a revolution in research that CIHR
was born exactly one year ago. Canadians place a great value on
health and the health care system. The creation of CIHR, with its
very broad and integrative mandate, explicitly recognizes that a
cost-effective and innovative health care system cannot exist
without a vibrant internationally competitive and strategic health
I am sure honourable senators are familiar with the Fyke report
out of Saskatchewan. That report emphasizes that research is a
pillar of the transformation to a high-quality health care system
that is both accessible and efficient.
CIHR has developed a bold and broad new vision with an
innovative structure that includes the creation of 13 virtual
institutes that span the entire spectrum of health concerns of
Canadians. CIHR is the primary agency through which the
Government of Canada funds health research.
I would also add that, although I do not think it is within your immediate mandate, CIHR is also key to building a
knowledge-based economy. In addition to contributing to a health
agenda and a more cost-effective health care system, CIHR-funded research and programs are contributing directly to
Canada's health-related biotechnology sector, a sector that is key
to Canada's growth in the 21st century.
In addition to the 13 institutes that were announced in July and
the scientific directors from across Canada that were announced
in December, we are bringing together researchers from all pillars
of health research, biomedical and clinical researchers, health
systems researchers and population health researchers, as outlined
in the legislation.
The advisory boards that were announced in January bring
together from across the country 218 volunteer Canadians who
will advise those 13 scientific directors about the strategic
initiatives that should be developed by CIRH's 13 institutes. This
is a brand new structure. We have never had this in Canada
before. Early signs are that it is working.
A key part of our mandate is to promote and disseminate
knowledge and the application of health research, to improve the
health of Canadians. CIHR is developing as we speak a
multifaceted knowledge translation initiative.
All levels of government need objective and scientific evidence
in order to make informed policy decisions, given the avalanche
of new treatments in the pipeline. Canada's health research
community already serves as a receptor for the world's scientific
advances. Canada is a small country, scientifically. Thus, we are
not only contributing to our own science, but also helping our
policy makers evaluate new advances, made worldwide, to guide
We need to understand this complex interplay between our
genetics and the psychosocial environmental factors that affect
our health and disease. We also need to worry about the ethical
implications of this new technology. For example, the government
is proposing to put into place a legislative framework around the
use of assisted human reproduction and the uses of the human
CIHR has anticipated a great interest in stem cell research for
disease therapy, and actually released, a few weeks ago, a
guideline for researchers in Canada for all CIHR-funded research
involving the use of human stem cell and human embryos. This
document has been received positively by the international
scientific community. Two weeks ago, Nature, the world's most
prestigious scientific journal, carried a story on our guidelines.
The story was entitled, "Canadian Panel Aims for Middle
Ground" - the usual place that we in Canada like to be in.
The Institute of Health Services and Policy Research will
support research to address the need for health systems,
technologies and tools to promote health, prevent disease and
deliver health care effectively for all sectors of the Canadian
population, as well as to evaluate the economic impact of the
health care system. I will not list the details of the mandate; it is
included in my written submission.
I give several examples where I think research funded by CIHR
has had an impact within the health care system, in terms of
saving the system money. There is an example on pneumonia that
I will not expand upon. There are also examples on heart attacks
and diabetes. As well, there was a study reported last week in the
prestigious New England Journal of Medicine on ear infections -
which is the most common reason that children are taken to the
doctor - that commented on the current practice and how these
operations are unnecessarily spending money without really
helping the children. If the guidelines of that study wereadopted, it would save Canada's health care
system approximately $300 million a year. That is not a bad return on
such an investment.
We are all too familiar now with the E.coli infections in
Walkerton, Ontario that led to several deaths, and other incidents
have been reported involving hamburger meat. Dr. Brett Finlay, a
UBC researcher, is a CIHR distinguished investigator.
Dr. Finlay's work is noteworthy on two levels - and this is
illustrative of what CIHR is about. He has elucidated in a
beautiful series of experiments exactly how E.coli causes kidney
failure and death and how it adheres to the intestinal linings in our
body to cause diarrhea and the like. As well, he has gone beyond
that science and, in collaboration with the Alberta Research
Council, the Saskatchewan Veterinary Disease Organization, and
Bioniche Incorporated, a biotech company in Ontario, has
developed a vaccine against that particular strain of E.coli, and
this vaccine is now being used to immunize cows. Cows are latent
carriers of that bacteria and undoubtedly the runoff from that herd
caused the problems in Walkerton. They are now doing
experiments with 300,000 cattle in Canada to see whether they
can effectively immunize them against E.coli and as such prevent
contamination of our water supply with that bacterium. That is a
great example of wonderful science and a partnership between
four provinces and the public and private sectors. Dr. Finlay is
also a wonderful communicator. He gives the annual Christmas
lecture at the Howard Hughes Medical Institute, in Washington,
D.C. This is something that all Canadians should take great pride
Another example is Dr. Jacques Simard, at Laval University.
He is working on genes involved in prostate cancer, following on
work that he had done earlier on genes involved in breast cancer.
We have just funded Dr. Simard with a large grant, including a
multidisciplinary team, to work on the genes involved in various
cancers, working with community groups in the population and
researchers from all four pillars to understand how these genes
work, how they can be used in diagnostic methodologies and, it is
hoped, to prevent and treat diseases.
I have other examples of CIHR funded work that, because of
time, I will not go through, except for one example, which is the
problem of diabetes in Canada's Aboriginal population. It is an
epidemic, to put it mildly. Over 50 per cent of Canada's
Aboriginal peoples have diabetes.
The Chairman: I saw that number and thought it might have
been a typo.
Dr. Bernstein: No, that is the right number. You might wish to
invite Dr. Bernie Zinman from Mount Sinai Hospital, who is
working closely with Aboriginal peoples on this very serious
Undoubtedly, the epidemic of diabetes in that population and
the complications and deaths that arise from that disease are a
combination of genetics, family history and lifestyle. Dr. Ann
Macaulay heads the Kahnawake Centre for Research and Training
and Diabetes Prevention. She heads a community alliance for
health research, a new program that we started this year that
involves researchers from McGill University and community
researchers in the Aboriginal community to develop and evaluate
a model for diabetes prevention in the Aboriginal population.
I have met with Aboriginal leaders from Sandy Lake, in
northwestern Ontario, about this. It is really a terrible disease. It is
a chronic disease. It probably is at least 50 per cent preventable,
and we need to be doing research and working with community
To conclude, in the short 10 months since the act was passed
that created CIHR, we have moved quickly to realize the bold and
broad vision that was set out by Parliament in this committee last
April. A slate of institutes has been named, including 13 directors
and advisory boards. They are actively developing their strategic
plans. I would love to list all of the ones that are on their menu.
We have funded two novel programs. I mentioned the Community
Alliances for Health Research. We have also funded another
program called Interdisciplinary Health Research Teams. Together, those 29 projects are an $80-million investment over the
next five years.
They involve over 550 researchers across Canada. The number
and breadth of CIHR-funded investigators has been broadened to
reflect our new mandate. The average size of grants has been
increased in 10 months by 20 per cent, an urgent step to make
Canada internationally competitive and to keep our best and
brightest researchers in this country. Most important, the Canadian
health research community has a new energy and optimism,
which is essential as we move forward in this new century.
Ten to 20 years from now, our health care system will
undoubtedly be vastly different than it is today. These profound
tectonic shifts will be largely driven by science. The health care
sector is truly Canada's largest knowledge-based industry, and to
contribute to this global health revolution for the health and
wealth of all Canadians our country needs a robust, innovative
and evidence-based health care system. We require a culture that
can respond to change, that can innovate and originate change, a
culture that recognizes and awards excellence and evidence-based
I know of only one way to achieve that goal. Although I look at
it through a distorted lens, I think that the only way to have a
culture of innovation is through a culture of research, and that
needs to permeate everything we do in health.
We are today in the midst of an unprecedented revolution in
health research. In a very real sense, the future of our health care
system depends on how successfully we both contribute to and
benefit from that revolution.
The Chairman: Thank you for that update. We are grateful to
hear what has happened in the year since we dealt with the bill.
You have addressed with the role of the federal government in
what I would call basic research; I want to move to the patient
end. There is tremendous pressure from patients to have the latest
drug, the latest device, the latest whatever. What are the stages
between the completion of one of your research projects and the
outcome of that research, be it a drug, a test or a procedure, being
available to Canadians?
My second question is related to that. What is the process by
which one decides whether it is worth doing, in a value sense?
Because we cannot afford all the bells and whistles, how are the
trade-offs made? They are obviously made, because some things
are offered and others are not; there is at least an implicit trade-off
mechanism. What is the process by which we determine that a
wonderful new toy is too expensive and would help too few
people to proceed with it?
Dr. Bernstein: First, just to correct a misapprehension, CIHR
does not fund only basic research, by which I mean laboratory
research on fundamental mechanisms.
The Chairman: I meant basic, as in a process that takes your
output and moves into the marketplace.
Dr. Bernstein: I skipped over some examples. We also fund
clinical research, including clinical trials. One example I skipped
over was the work by Dr. Yusuf on the drug Ramipril. We are
funding a very large study with Dr. Yusuf in collaboration with
two pharmaceutical companies. We have learned that Ramipril
might prevent diabetes, so we are now funding a $2.5-million
clinical trial on patients to see whether, in a larger group of
patients, Ramipril really will prevent diabetes.
We are also funding this year, for the first time, a tri-national
study involving the U.S. and the U.K. on new therapeutic
modalities for HIV/AIDS. In addition, the health services pillar of
CIHR will be evaluating the health economics of any new
innovation within the health care system.
On your second question, one can make great advances
scientifically, but someone must evaluate their cost effectiveness
in the real world.That is the function of the Institute of Health
Services and Policy Research headed by Morris Barer. They are
asking questions exactly along those lines. We are hoping then to
have a venue to transmit that information as part of our
knowledge-transfer mandate to policy makers across the country. I
have already met with deputy ministers of health across Canada to
set up ongoing dialogues with them about scientific and research
innovations and to convey to them the latest results and the
advisability of incorporating them into Canada's health care
These are big issues and we need good and objective data to
evaluate them. I totally agree with you.
The Chairman: What does Morris Barer's organization do?
Dr. Bernstein: Of the 13 institutes within CIHR, one is Health
Services and Policy Research. You will see that on page 4 of the
overheads we have provided. The mandate of that institute is to
evaluate the cost effectiveness of innovation within the health care
For example, if Dr. Yusuf finds that Ramipril really is effective
in preventing diabetes, one of the functions of that institute will be
to look at the cost of that drug, look at the number of people with
diabetes, look at the side effects, and evaluate whether it makes
sense to recommend Ramipril to people at risk of getting diabetes.
The Chairman: Is there a document that summarizes what that
institute is working on now?
Dr. Bernstein: Currently, all the institutes are developing their
specific strategic initiatives. The broad mandate for that institute
in particular is listed at the beginning of my presentation to you. I
am sure that Dr. Barer would be very happy to appear before this
The Chairman: This is very important. There is no sense in
hearing from him before he completes his strategic plan, but can
we assume that it will be done before we rise in the middle of
Dr. Bernstein: Absolutely.
Senator LeBreton: There is much information here. It is
obvious that the delivery of health care will change dramatically.
You talk about it going from reactive to proactive. I will use
Alzheimer's disease as an example. As researchers are able to
identify genetically or by other means conditions that signal that a
person may be a candidate for Alzheimer's, those people will
begin to be treated. Are other bodies looking into the positive
economic outcomes of that? For instance, with the growing aging
population, there are increased numbers of people in chronic care
facilities. That number may decrease in 10 to 15 years as a result
of new research and treatment. Has there been a study on the
savings that will result from that?
Dr. Bernstein: That is a very good point. I think it is our
responsibility, senator. There are health economists in the country
whose research we will be funding. They will look at the
economic burden of disease and, therefore, the resultant savings
of either eliminating or ameliorating the disease or shortening
hospital stays, et cetera.
I have given examples concerning pneumonia and ear
infections. I give dollar values in that regard. Some of that
information is available, and some of it is very hard to get. You
are right, senator, we need to document that very well.
Senator LeBreton: As your research continues, you will have
to look at the anticipated crossover point. That is to say, when you
look at the next 10 to 15 years and consider the gradual shifts in
the system, you will have to consider where it crosses over from a
reactive to a proactive health delivery system.
Dr. Bernstein: I think we are seeing the tip of the iceberg now.
Colon cancer is one example. In my previous life, I was director
of research at Mount Sinai Hospital in Toronto, which houses the
familial colon cancer clinic for southern Ontario. If an individual
has a family history of colon cancer and comes through the door
of that hospital, some DNA is taken and the gene is sequenced.
This is done even before any symptoms appear. The individual is
then followed on an annual basis and the polyps are removed. We
are starting to see that happening increasingly. It will permeate the
health care system within 20 years.
Senator LeBreton: It will cross over in degrees, then.
Dr. Bernstein: It will happen incrementally, as these risk
factors are identified.
Senator LeBreton: But as people come to expect a better
delivery of health care, the impact could be huge.
Dr. Bernstein: Expectations will also rise with these advances.
Senator LeBreton: Once the research is done - and Senator
Kirby talked about getting it out to the patient - will there be
more pressure placed on practitioners? The practitioners are busy,
and the health care system has many patients. What about the
individual who has genetic proof of familial breast cancer? How
will information be disseminated to the population at large?
Dr. Bernstein: I talk a little bit about the Web as being one
way of democratizing knowledge in the health care system.
Consumers are becoming very knowledgeable. Quite often,
individuals with disease X, Y or Z will search the Web to learn
more about that disease. They often end up knowing more about
the disease than any physician will ever know about it. It is hard
for physicians to keep up with all these advances. One of our
knowledge-transfer functions is to ensure that information about
research advances not only is transferred to policy makers but also
to health professionals, such as physicians, nurses and other
caregivers. In this way, we will be delivering the very latest
advice and science within the health care system. It is a challenge.
Senator Robertson: Thank you, Dr. Bernstein, for attending
here this morning.
My questions relate to something that Senator Kirby identified,
as well as to something Senator LeBreton touched upon.
We hear a lot of moaning and groaning about the cost
effectiveness of research for new programs. I have always felt
that, if research looks after the side effects and ensures that one
can live with them, the next step on the part of researchers is to
ensure that the end result of the research, whatever it is, can be
made cost effective. It seems to me that the two go hand in hand.
One should not throw up his hands and say, "We cannot afford
that," because, as you identified correctly, the system will change
radically. However, there is some responsibility in the research
end of things to determine cost effectiveness, to the point at which
the public can feel comfortable. There have been many new
health care innovations, drugs, et cetera; however, if we measure
their cost against the heavy cost of traditional-style care, of
keeping patients in hospital beds for protracted amounts of time,
goodness knows what we could come up with. There is a trade-off
Dr. Bernstein: I agree with you. I gave examples involving
pneumonia and ear infections, where CIHR-funded work has
looked at current clinical practices in hospitals and questioned it.
In the case of both conditions, our research has asked: Is current
practice the best way to treat this disease? The answer in both
cases was no, that more cost-effective methods are available, thus
saving Canada's health care system hundreds of millions of
Senator Robertson: It is important for the public to understand
these things. The value of the research, I believe, follows that path
and makes people comfortable.
Senator LeBreton touched on the plight of physicians and
health providers. There is currently a shortage of physicians, and
this shortage will continue because of the time required to train
physicians. I look at my little province and wonder how we will
keep up to date with the research. How will the medical schools
respond? How will we retrain? Its seems to me that retraining all
the people involved in the delivery of health care will be required.
I am not sure if applied practical research has to go into that.
Will current medical practitioners be overwhelmed by this? Will
they be able to absorb it? How will we educate not only those in
the medical and nursing schools but the army of other people
currently working in the field?
Dr. Bernstein: You are all identifying a challenge, and it is a
real one. The professional bodies, such as the Royal College of
Physicians and the Canadian Nursing Association, are well aware
of this avalanche of new information. There needs to be ongoing
continuing medical and health education for health professionals.
That is one reason I made the comment in my closing remarks
that in order to have an innovative and leading-edge health care
system we need leading-edge health research enterprises. It is
these people who are at the front lines who can do that ongoing
medical education and dissemination of new knowledge.
If CIHR were to disappear tomorrow, if Canada were to decide
that we do not need to do health research because we are a small
country and we can import it from the United States or Europe,
we would immediately lose all our researchers, including those
people in the health care system. They are the people who are the
nodes, the centres of immediate new knowledge. They can talk to
their colleagues and say, "There is a better way of doing this, that
or the other thing." We would lose that immediately. That would
be one huge negative impact of not having a vibrant health
research enterprise in Canada.
Senator Robertson: I applaud the research. I agree that we
need as much as possible. The more money we can direct at
research, the better off we will be. However, let us go back a few
years. Do you know the name of the first ulcer pill? I cannot think
of its name right now. Do you remember how upset the surgeons
first were when ulcer patients began to be treated by drug therapy
rather than by surgical methods? The surgeons practically ran
those allies of drug therapy out of the hospitals. Our most difficult
challenge may be to change the perception and the practices of
some people in the health care system.
Dr. Bernstein: I agree with you. My closing comment is that
there is a culture of research. Research always questions. If there
is a culture of research that permeates the health care system, it
makes it easier to innovate within the health care system.
Senator Cohen: Senator Robertson and Dr. Bernstein referred
to our little province of New Brunswick. In looking at your
scientific directors in the institute, I notice that the Atlantic region
is not represented there at all. There are illness that are unique to
our area. I know that the Alzheimer's Society is studying a family
in the St. John River Valley that has had generational cases of
Alzheimer's; asthma is another area.
How are you getting your information on the Atlantic
provinces? Is there an advisory board with respect to the Atlantic
region? Do we not have people who would be capable of serving
in this area?
Dr. Bernstein: I absolutely agree with you. It is important,
based on the arguments that I have been giving to you, that CIHR
be represented right across this country, and it is. You are right,
there are no scientific directors from the Maritimes, but the
advisory boards have strong representation from all regions,
including the Maritimes.
Mavis Hurley, from New Brunswick, is on governing council;
Alastair Cribb, from Prince Edward Island, is on governing
council; Nuala Kenny, from Nova Scotia, is on governing council.
It is important to note that we are funding a significant amount of
research in the Maritimes. We have just made a $3 million
investment into Maritime safety - health research, broadly
I have appointed Dr. Renée Lyons, from Dalhousie, as my
special adviser on the delivery and continuity of rural and remote
health issues, which is obviously a unique problem for Canada.
As well, I have encouraged the research community in the
Maritimes to get together and determine how they can best take
advantage of the federal funding through CIHR. I was in P.E.I. in
January and attended a meeting of the nascent health research
institute. I have actually given a bit of money for researchers from
the four Maritime provinces to meet and form an eastern
Canadian health research institute that will facilitate them being
nationally competitive and take advantage of funding from CIHR.
Senator Cohen: I am glad to hear that. My case rests at the
What is the future of the Maritime Centre of Excellence for
Women's Health in the Atlantic region at this point?
Dr. Bernstein: You would have to ask Health Canada. That is
outside my area of immediate purview. Senator Morin might
know, but I am not sure.
Senator Morin: Dr. Bernstein, as you stated earlier, CIHR is
the only organization that is devoted to the full spectrum of health
research in the country.
On the basis of what is being done in other countries, and from
your own experience, what should be the budget of CIHR in
relation to the total health care cost in the country of $80 billion?
What percentage should we aim for, in view of the increasing
importance of research, as you stated earlier?
Dr. Bernstein: Let me try to answer in two ways. I said in my
presentation that health care is Canada's largest knowledge-based
industry. If I were a CEO of Health Canada Inc. and said that we
are going to double our spending to 1 per cent of our total budget
on research, you would fire me if you were on the board. You would say that 1 per cent is ridiculously low for a
knowledge-based industry. Despite Nortel's problems, Nortel and
all the high-tech companies down the road here in Ottawa spend
between 20 per cent and 40 per cent of their revenues on research.
How else can they be at the leading edge?
At the moment we spend through CIHR, as a country, about 0.5 per cent on health research. In
round numbers - and I am rounding up - we will receive
about $500 million this year for CIHR, which is a significant
increase from what it was. Our health care budget in total for the
country is approximately $100 billion, so $500 million is
approximately 0.5 per cent.
My own judgment - in terms of the broad mandate that you gave us a year ago, in terms of international benchmarks in
other countries and the capacity in this country to do the research,
is that we should grow over the next three to five years to that 1 per cent level, which would be a doubling of where we are
now. Others would argue that is too modest, that we should be
above that. My number would be $1 billion, which would be
approximately 1 per cent of today's dollars spent on the whole
health care system.
Senator Fairbairn: What a tremendously upbeat presentation;
it has been a delight to hear. I have listened to your emphasis on
the fact that health care is the largest knowledge-based industry,
and you have focussed quite properly on efforts to democratize
this knowledge, use the new technology to get it out, have the
Institute of Health Services and Policy Research reaching out to
disseminate as best they can into communities and services that
actually deal with people.
My question goes to the issue of the ability to understand the
knowledge that you are hoping to pass down through practi tioners, and that leads me to the question of the millions of people
in Canada who are at risk because of their low literacy skills, their
inability to comprehend at a certain level of information. We will
hear from Scott Murray from Statistics Canada on this issue as it
pertains to older Canadians.
Generally, most people experience some difficulty trying to
understand instructions from medical practitioners, reading and
understanding prescriptions, formulas for kids, all those kinds of
things. Is the institute involved in any manner with literacy issues,
with reaching out and assisting those who most need help in the
area? Are you factoring this into any of your considerations?
Dr. Bernstein: That is a good point. We are not funding
literacy issues directly. It is interesting that one of my first trips as
president was last June to UBC in Vancouver. I happened to meet
there a professor of English who was interested in health. I asked
her what her specific interest was. It was exactly around these
areas, about language as metaphor in the health care system,
about the issues of telling an individual that he or she has cancer,
about the fact that first-generation Canadians and their families
will receive the information in one way, whereas fifth-generation
Canadians will receive it in another.
I became very interested in exactly this issue. We are funding
her to do some work with clinicians on how they interact with
families and patients who are affected by the news that they have
cancer or some other serious disease.
With regard to how we reach "ordinary Canadians," Canadians
are very quickly getting up to speed on using the Web. They are
very interested in it as a portal to the world's knowledge. As one
way of reaching out to the country, we are developing a research
portal concept. There will be one Web site for all Canadians, be
they researchers, caregivers or professionals in the health care
system. The site will be called "Research Net." It will contain
information for everyone, from students in grade 6 doing a
science project on health, to health professionals learning the very
latest in the field, to researchers who want to know how to apply
to us for money, to policy makers across the country who are
interested in the latest evidence-based decision-making issues
with which they must deal.
There will be subportals within that one portal. My information
technology people are working hard, in partnership with the other
federal granting councils, the health charities, the provinces and the government online initiative, to realize this over
the next 12 months.
We are leading this discussion and I am very excited about this
as an innovative way of reaching out to Canadians.
Senator Fairbairn: Last year, the Public Health Association of
Canada, for the first time ever, chose to have its annual
cross-country conference on the issue of literacy and health. I
leave that with you because this affects about 8 million people in
our country. Over 40 per cent of our adults have these problems.
It is a side issue to what you are doing. I am just waving the flag
and hoping that at some time a special focus could be put on this.
Senator Graham: Thank you and welcome. In your presentation, you talk about the future. You say thatthe $110 increase in funding for fiscal 2001 and 2002 represents
significant support for health research in Canada, bringing the
federal government's total investment in CIHR to $477 million,
or approximately .5 per cent of Canada's total health care budget.
You go on to say that international benchmarks suggest that a
minimum of 1 per cent of a country's health care budget is
essential to maintain a vibrant, innovative and leading edge health
I recall meeting with the president of what was then the
medical research council prior to the health budget, as it became
known. After the presentation of the budget, I asked him his
impression of it and he said it was stunning. In spite of his term
"stunning," are we still only halfway there?
Dr. Bernstein: The trend line is in the right direction. With
that $110 million increase this year, our budget has almost
doubled over that of the old Medical Research Council, and that is
in a short three years. That is a huge recognition by the
Government of Canada of two things: the importance of health
research and the shortfall in the budget of the old NRC.
The trend line is in the right direction, although we still have
significant room to grow over the next five years.
Senator Graham: Can you give us an example of countries
that are at 1 per cent?
Dr. Bernstein: I can give you dollar amounts but not
percentages. This year, the National Institutes of Health in the
U.S. received a 14 or 18 per cent increase in their budget, to
approximately $18 billion U.S. Therefore, they are currently
four-fold to six-fold per capita above where we are. The U.S.
spends more per capita on health care than does Canada, so one
can safely assume that that is about 1.5 to 2 per cent of their
health care budget.
With regard to U.K., it is about 2 per cent of their health care
budget. They have legislation that requires that, within the
National Health Service, 1 per cent is spent on research. However,
they actually spend more than that on research.
Senator Graham: I want to talk for a moment about
cooperating with the private sector. You illustrated an example
where you are investing $2.5 million with one pharmaceutical
company for some particular research. How widespread is that
cooperation between CIHR and the pharmaceutical companies?
Dr. Bernstein: I would say that roughly 3 per cent of our
programs are in partnership with pharmaceutical companies. In
clinical trials, for example, it would be illogical not to partner
because the pharmaceutical companies have so much to add, not
only financially but with access to the latest drugs, et cetera. We
also partner with them in training young people, particularly
young clinicians in research. They provide some of the salary
support in partnership with us to train young people.
Senator Graham: Do you partner with institutes in the United
States in your research?
Dr. Bernstein: Health and health research is not a Canadian
problem; it is an international issue. There is great international
interest in the CIHR structure, model and vision. We have been
visited by the Netherlands. I have been invited to Australia to talk
about CIHR. Our scientific directors have been to the National
Institutes of Health to talk about partnering in the North American
free trade area on cardiovascular and cancer research, and that
area will broaden over time. I visited the U.K. two months ago to
talk about a joint initiative with the Medical Research Council
there around various projects, although we have not yet finalized
what they will be.
Yes, there will increasingly be international partnerships in
health research between Canada and other countries.
Senator Graham: In response to what I think is a justifiable
concern expressed by Senator Cohen with respect torepresentation from the Atlantic area of our country, you said that
you were encouraging the scientific community in Atlantic
Canada to get together. Does that suggest that they are not
currently cooperating as best they should to take advantage of
money that might be available for scientific research?
Dr. Bernstein: No, I do not mean to suggest that at all. An
issue in Canada as a whole is our geography. Science research is
all about critical mass and having lots of other researchers around
you. The public image of researchers going into a lab and coming
out every 10 years to talk to someone is entirely wrong. Research
is all about meeting other researchers, talking about what is new
and being stimulated by your colleagues. In many regions in this
country, including Atlantic Canada, it is hard to get a critical mass
because of the population structure and base. Therefore, I have
given a little bit of money to help people get together.
In response to Senator Cohen's question, I did not mention that
we have a regional partnership program for which only the
Maritime provinces and Saskatchewan are eligible. We have put
up $1 million or $2 million, and we expect the provinces to match
that, to specifically stimulate health research in those five
provinces. There has been great uptake of that money by both the
Maritime provinces and Saskatchewan. That is separate from our
national competition. Only those five provinces are eligible for
Senator Graham: When I was in cabinet, I met with many
people in the Atlantic provinces and here in Ottawa who said that
there was room for greater cooperation in the scientific
community among our institutes of higher learning in Atlantic
Dr. Bernstein: There is always room for more cooperation. I
do not think at all that Atlantic Canada should be singled out in a
critical sense for that. I would say that the mood in this country
has changed a lot in the last few years towards more cooperation,
and the recognition that we need, not just Dalhousie talking to
Memorial, et cetera, but to have biomedical people talking to
clinical people and health services people. The creation of CIHR
has served to be a major catalyst for all of that.
The Chairman: Thank you, Dr. Bernstein. We are pleased to
get your update. We should do this on an annual basis so we
know where you are going.
Dr. Bernstein: It would be my pleasure.
The Chairman: In order not to lose sight of a point we talked
about earlier, once the Institute of Health Services and Policy
Research has its strategic plan - and I would also argue once the
Institute of Population and Public Health has its strategic plan -
we would like to hear about that.
Our next witness is Kimberly Elmslie, the Acting Executive
Director of the Health Research Secretariat in Health Canada.
Before Ms Elmslie begins her presentation, I wish to say, in
response to Senator Graham's question about where Canada
stands, that in a document circulated by our staff there is an
interesting table on page 8, which compares health care spending
by country. It is interesting, in that generally Canada is sixth on
various per capita data kinds of numbers. I am not surprised that
we are behind the U.S. I am rather surprised that we are behind
France and Australian. That is counter-intuitive to me, and wrong.
The data is right. I do not like the result.
Ms Elmslie, thank you for attending here. I know you arrived
during the previous discussion, so you know what Dr. Bernstein
had to say to us. I would ask you to review the highlights of your
brief, and then honourable senators will ask you some questions.
Ms Kimberly Elmslie, Acting Executive Director, Health
Research Secretariat, Health Canada: Honourable senators, I
am delighted to be here. This is an important opportunity for me,
and I am also happy to be following on Dr. Bernstein's
presentation. There will be some similarities in the things we have
to say. I will talk about some things that I have learned from my
experience in the research field and from working in a federal
health department with provincial and territorial colleagues, issues
related to health care and the health care research system and
observations that may again reinforce some of the comments that
I heard senators make around the table earlier.
Let me start by giving you a bit of the landscape. We have, in
the federal government, a multifaceted role in health research and
in health care research, and more and more are getting involved in
facilitating efforts to influence priorities, to bring more precision
to discussions about what our health care research priorities
should be. We are highly involved in undertaking research ourselves in areas that are directly related to federal
responsibilities in the areas I will point out, particularly of health
protection and risk management.
I am sure Dr. Bernstein has talked to you at great length about
the funding of extramural health research and related science in
engineering research, and the new and improved ways that we are
striving to move health research forward in this country. I will not
go into the details around that.
I wish to talk about other organizations that in this country will
be essential to moving the results of research into the eyes and
ears of the Canadian public, to policy makers and to those in the
health system who need to have information on a regular basis.
We all know how inundated we are with information. Thus,
there are specific challenges to us regarding organizations like the
Canadian Health Services Research Foundation - a federally
funded organization dedicated to engaging in research that looks
at the health system specifically. Our challenge is to bring the
results of that research into the policy processes and into the
dialogues that Canadians are having at various levels about
One of the take-away messages that I want to bring to your
table today relates to investing in the transfer of research into
decision-making processes, learning how to do that more
effectively and really thinking about that in the context of the
whole research process.
Organizations like CHSRF, the Canadian Health Services
Research Foundation, are certainly common entities around the
world these days. You only need to do a quick search of the Web
to see that governments around the world are dedicating resources
to the transfer process. It is no longer seen as the second cousin to
the research process. We are seeing governments saying that they
are really not using research to its full potential. We have invested
for a long time in the front end, and we are doing more in the
front end, especially with the Canadian Institutes of Health
Research now in the Canadian landscape. However, we must
think about how to use that research most effectively to the
benefit of Canadians.
Another organization that I would like to highlight is the
Canadian Institute for Health Information, which is another
important national entity that brings data into the decision-making
process. The federal government has enhanced funding to that
organization in the 1999 budget to really focus its efforts on
reporting on the health of Canadians and the health of our health
care system. We must ask ourselves about how we ensure that we
are mobilizing research and directing it in a way that brings its
benefits to Canadians and about how we know that our health
care system is doing what it should do to improve health
We have all been thinking a great deal about these questions
over the past years, not only in the past two years when CIHR
was in formation but for a long time. We know that the health
care system is only one piece of a much larger puzzle, and we
know that health is about much more than that. Studies have been
coming to the fore that compellingly demonstrate the influence of
the social and economic factors in our environment on the health
status of our population.
No one research discipline can answer the fundamental
question of why some people in our population are healthy and
others are not. This speaks to and illustrates the absolute
importance of the CIHR model of integration that brings together
researchers from a multiplicity of disciplines and says, okay, here
we have the problem. How do we understand better what are the
main factors and the interactions between factors that result in
positive and beneficial health outcomes in some groups of our
population and absolutely appallingly negative health outcomes in
other segments of our population? I am making reference here to
our Aboriginal peoples and the circumstances in those populations
that we need to understand in concert with Aboriginal communities, and not as researchers looking into Aboriginal
Research is an important tool, but the tool is only as good as
the use we make of it. Without investing in the transfer piece that
one of the senators on this side of the table made reference to
earlier, we are really missing the opportunity to be able to see
positive outcomes in the health of the population.
What is at play? The list on the bottom of page 2 is not rocket
science. We all know these things. They include the changing
demographics of our population and patterns of disease. We know
that infectious diseases are re-emerging. We can expect new
infectious diseases to emerge in this century. Those who thought
years ago that we had beaten the infectious disease challenge, of
course, are realizing that they were sorely mistaken and that this
is something that the population globally will be dealing with for
centuries to come.
We are seeing rapid advances in science and technology. They
are very exciting. However, we cannot forget the social and
ethical issues that they raise for us as a society and as a
population. Research that moves us forward, for instance, in
genetics and genomics, needs to be accompanied by a vigorous
research agenda in the ethical and social aspects and implications
of that research. The purpose of the agenda is not in any way to
prevent bringing the benefits of that research to the population. Its
purpose is to understand the impacts on what we value as a
society and what we need to do to put the pieces together in a way
that Canadians can understand and make informed choices
concerning the options that become available to them.
Public expectations are on the rise. When I started working in
the field of health about 20 years ago, my first job was in the area
of HIV/AIDS. Any of you who have been in that area will have
witnessed the explosion of information that patients were using to
direct their own health care at that time. Many other areas were
not experiencing that. I truly believe that it was HIV/AIDS that
brought us forward in understanding that patients, consumers,
work with their providers to decide on the best choices for them
in terms of their health care. The public expects that. As we get a
more knowledgeable public and as the information revolution
continues and we obtain more knowledge on which to base our decisions, there will be an increasing demand for more
information from the public and greater involvement in decision
Are we equipped as a society? Is our health system able to deal
with that increasing demand? Probably not right now.
Rising costs and concerns about effectiveness in efficiency are
not new phenomena, by any means, but clearly they have risen to
the fore as we look at new pharmaceuticals coming on to the
I deal now with the drive to commercialize, which, again, is not
in and of itself a negative thing at all. However, it needs to be
within a framework that allows us to ask these questions: How
does our system cope with this? What does it pay for? How do we
Overarching issues around health care quality, the access to
care, health outcomes and system affordability continue to be at
the centre of the dialogue on health care. As a country, we need to
think about the architecture, management and financing of the
system. Again, these are words that are not new to anybody
around this table. I put them out again because in the face of the
new CIHR and its Institute of Health Services and Policy
Research - and, in fact, all of its institutes - we need to be
thinking about tying the outcomes of research to the system that
delivers the products of research to our population. Therefore, I
see health care research as a very integrative and unifying piece of
Canada's health research agenda.
There is also an important role for our voluntary health sector. I
have highlighted this in my brief because I have been involved
recently in some consultations around research. The role of the
voluntary health sector keeps on coming forward as we think
about new models for this century, new ways of integrating care
and the fact that Canada has a very caring and volunteering
How do we best value that, in the context of the health care
delivery system, recognizing that caregiving happens in a lot of
different places in your society? The relative roles of informal and
formal systems of care present us with new opportunities and
challenges. We need to bring that into our thinking about research
and how we mount a research response.
I have some thoughts for you on the way forward. I do not
think anyone would disagree that the CIHR model is the right
one. The word "integrate" keeps coming to my mind as I look at
the way we are dealing with the new CIHR. That is to say,
integrate the ideas, the talent and the resources. We are trying to
create an environment that harnesses Canadian research talent and
draws together the stovepipes, the separate entities, and gets
people talking about the right solutions. In some ways, it is as
simple as that and as complex as that.
I would like to raise two challenges - and, again, they do not
involve rocket science. Do we know what we know and therefore
what we need? We tend to get caught up in the potential of new
science and discovery. We need to ground ourselves and ask
ourselves what it is that we know and what it is that we do not
know. We have to know when to ask ourselves, "Do we need to
take some action here?" Those are some of the questions that
come to my mind as a I look at a research and science agenda.
How do we use what we know in order to change what we do?
It seems like a simple question, but we are not doing a good job
in Canada of getting research into practice. We know that the
clinical practice guidelines that are available do not change
physician behaviour. Information does not change health policy development. It does not influence it enough. Traditional
publishing of health research in journals is not enough. This is an
area of focus that we really need to put some of our creative
talents behind. I have no doubt that we can do that.
Synthesis of research findings is important in assessing the state
of the art. It is rare that one research project, or even a few, is
enough to bring us the evidence we need. It is the power of many
good research studies and good research champions that brings
together information from science and makes it real to people and
to organizations so that they use it.
Evidence consolidation is a business that many are in right
now. We have to determine how to broaden that scope and how to
bring it into our mindset. Dr. Bernstein talked about the idea of
the culture change. That is part of it. We also have to ask this
question: What important tools do we need to put into place?
I would say that we are on the right track. For the first time,
CIHR is starting to specifically align research with policy needs.
We have to see how it works. We know that that is the intention, but we have not had time yet to see it actually work. We
are all committed to evidence-based information. We need to
direct some attention - and we are starting to do this - to
health-care-system-level evidence and to the impact of making a
change in one part of the system. We must ratchet up our lens to
say, "We have a big system" - some would say many
systems - "operating out there. When we make a change in one
area, how do we look at the impact of that on other parts of the
system, to maximize the benefits?"
Analysis of the effectiveness and appropriateness of new
approaches to care will be important to our system as we get it
ready for the future. Many predict that the acute care system will
change dramatically because of the availability of new drugs and
new approaches to care delivered in the home, telehealth and
telehome care. These are all words that are on everyone's radar
screens, but what do they mean to us and how do we know that
the health outcomes and the quality that we are delivering to
Canadian is where we want to be?
More health care outcomes research is critical. We do not know
yet what works. That will be a very important guiding feature for
Finally, I will make the observation that the building is only as
solid as the foundation. We are on a very important track with
CIHR to mobilize health research, to train and build the capacity
for health research in Canada. We still have a fairly small health-services research community. We need to attract
researchers into that area. By doing that, we will achieve the
important outcome of keeping that talent in Canada, where we are
desperately needing it, if we are to turn a huge system around or
even modify it in important ways to meet the health challenges of
The Chairman: Before turning to my colleagues, I wish to ask
you a specific question. On page 4, where you say "we are on the
right track," you then list the bullet points you just talked about. Is
that kind of work - the effectiveness, the research, the outcomes
research, and so on - being done elsewhere than under the
mandate of the Canadian Institutes of Health Research?
In other words, are there other organizations doing that; if so, is
there a synopsis of what is going on in the country in that area?
Ms Elmslie: The answer to your first question is, yes, health
outcomes research is going on in other areas by organizations
other than CIHR. As to the synopsis question, I believe there may
be pieces of that, but not a consolidated piece of which I am
aware. I would be more than happy, though, to look at that and
provide the committee with what is available.
The Chairman: That would be helpful.
Senator Morin: We might hear from the national centres of
excellence on evidence-based medicine then. This is exactly what
people have been trying to grapple with.
The Chairman: We would appreciate anything you can give
us on that, and picking up on Senator Morin's point will be
Senator Robertson: You raised something that I thought was
rather important. You spoke about the health of our health care
system. Has there been any research on the socio-economic
conditions, for example, of our medical students?
Ms Elmslie: That is a good point. I am not aware of any
specific research on that particular point, senator.
Senator Robertson: Where could we find that information? I hear different things in different quarters about
the socio-economic difficulties or not of medical students; it is
difficult sorting the rumours from the truth. I should like to obtain
information on that subject.
Ms Elmslie: I will undertake to get that.
Senator Robertson: What socio-economic class are doctors
recruited from? If we were to look at the first year classes of the
country's medical schools, would we find that a majority of the
students were from well-to-do families or would we find that they
were broadly representative of all income brackets in the
population at large?
There is the belief out there that talented students, who
otherwise would apply to our medical schools, decide to pursue
other studies because of the huge financial implication of a
medical education. I have been told that because of the cost
implications of a medical education we are losing some of our
I know that medical schools have bursaries and that sort of
thing; nevertheless, it is a shame if we are losing some of our
extremely bright young people. I am very interested to know
whether there is research out there to confirm or deny that.
Ms Elmslie: There is a researcher whom I know at McMaster
University that has done quite a bit of research into the medical
student array, if you will, in Canada. That would be my first
Senator Robertson: It is important for Canadians to know that
we are attracting our best and brightest.
Senator Graham: As well as keeping them.
Senator Robertson: Yes, but we have to get them in first.
Are there enough medical schools in Canada, compared to
other OECD countries? Perhaps Senator Morin will address that
I would be most appreciative of any information you could get
for me on these questions.
Ms Elmslie: Thank you. I will definitely follow up on that.
Senator Robertson: The Department of Health is so big
nowadays that it is difficult even to find one's way through the
directory; it is almost impossible to determine where to go to get
Could we get a simple directory of all the divisions in Health
Canada, so we know what we are talking about?
Senator Morin: It depends what day of the week you are
talking about. They change every day.
Senator Robertson: I agree with you, senator.
What division of Health Canada is responsible for the research
and approval for drugs? That is not your division, is it?
Ms Elmslie: No, it is not.
Senator Robertson: At some point it would be interesting to
have a discussion, Mr. Chairman, about the possibility of
coordination with other countries of the approval process. We
might get a better system in place. There is much general
discontent with the approval process.
Ms Elmslie: The branch in the department responsible for that
is the Health Products and Food Branch.
The Chairman: Senator Robertson, you are not alone. In the
year and-a-half that we have been in this job, we have received an
incredible number of organizational charts for Health Canada; if
you add to that the number of personnel changes, the figure is
Senator Graham: What you are saying is that it gets
confusing, Mr. Chairman.
The Chairman: It works on the assumption that there is
someone who truly understands.
Senator Graham: Having heard the witness say, "Do we know
what we know?" I am reminded of the old expression, "We are all
here because we are not all there." One hopes that we will be able
to justify our existence as time goes on.
I am particularly interested in the questions that Senator
Robertson asked. I hope we are able to get answers to those
questions. If not, then why? There has to be a mechanism to find
I am interested in the general picture. Is the secretariat, which is
relatively new, the link between Health Canada and CIHR?
Ms Elmslie: We are one of the links. Our intent, when we
formed the secretariat at the time that CIHR was launched, was to
ensure that the department understood and was taking full
advantage of the opportunities to work together with CIHR.
In the past, in the days of the medical research council, the organizations were separate entities. There was some
collaboration, but both organizations felt there was room for
more. The secretariat provides, if you will, a navigation function
to link into CIHR at the corporate level and to the institutes to
determine where we can work together, where it makes sense for
us to join forces and combine our resources.
Senator Graham: Was the function of your secretariat fulfilled
under another name prior to the reorganization?
Ms Elmslie: No, it was not. It is new.
Senator Fairbairn: My question is becoming a perennial one
at the committee, and I take it from your question about how to
use what we know in order to change what we do. My question is
about the degree to which Health Canada can be a leader in
getting information to Canadians who have difficulty with basic
reading skills. It goes to your concern about issues of taking
health care into the home, thereby shifting responsibility to the
person who has to manage his or her own situation.
Ms Elmslie: It is an incredibly important issue, and one that we
do not spend enough time thinking about.
One way I have seen information being brought into the home
and being used in a situation where literacy levels and
understanding may not be at the highest level is in the whole area
of working with our immigrant populations.
I think we can learn a lot from the Metropolis experience. For
those who do not know about Metropolis, it is a research program
concentrating on immigrants living in urban centres in the
country. It is funded by a number of federal government
departments. People working in that area are spending time on
this question of transfer of information, boiling it down and making it
understandable to people from various cultures and in various
Although I do not have answers to the question, I think there is
a recognition out there that we have to get better at it. We have to
use what communities are already doing through community
associations and other grassroots organizations and not just rely
on what we think is best for everyone else. We have to really
engage and start to work with those community organizations that
on a daily basis are out there with real people in real
circumstances who need real help.
Senator Fairbairn: A great number of them are not from the
immigrant population; they are home grown.
Ms Elmslie: You are absolutely right. I am thinking of models
that we may be able to draw on, and that model came to my mind,
but I take your point that they are Canadian people who are home
grown as well.
Senator Fairbairn: Keep at it.
Ms Elmslie: Yes. And if anybody figures it out, call me?
Senator Morin: Under the influences of the health care
system, most governments are faced with two factors. In addition
to changes in age and so forth, public expectations have
increased, and we are faced with demands for costly procedures
or drugs that are only marginally effective. Every provincial
government has been lobbied about drugs - for example, drugs
for multiple sclerosis. These powerful lobbies pressure governments to give them drugs or procedures or technologies that are
marginally effective but extremely expensive.
I am sure you have thought about this issue. This problem is
one we have been trying to grapple with. How would you deal
with this situation?
Ms Elmslie: That is the $6 million question, so to speak. You
are absolutely right, Senator Morin. There are a variety of
pressures on government from many different sources to bring to
Canadians various products, drugs, and pharmaceuticals in a very
To be overly simplistic, it comes back to knowing what works
and what are the marginal costs that are associated with the
delivery of various products, drugs and interventions to the
To me, it is a matter of looking at better studies of intervention
effectiveness, cost-effectiveness and benefits, and being rigorous
in those evaluations so that they become one piece of the
evidence base. They are not always clearly the only piece that we
can use in making those kinds of decisions. However, if we do not
even have that evidence, then we are only working on the basis of
pressure and opinions. I think we all want to be working on the
basis of sound science wherever we can. I do not mean to imply
that we have to wait for definitive answers before we take action,
because I do not think that is appropriate. We need to put
ourselves to the task of building the evidence base so that we can
use it as part of the decision-making process.
Senator Morin: Following Senator Robertson's point here,
what is the Applied Research and Analysis Directorate? That is a
new one for me.
Ms Elmslie: I will probably be naming another new one for
many of you. The department, about two years ago, created a new
branch called the Information Analysis and Connectivity Branch.
In that branch, the Applied Research and Analysis Directorate is a
Senator Morin: Do they actually conduct research?
Ms Elmslie: They conduct some in-house research on existing
databases. They also work with organizations like the Canadian
Institute for Health Information and Statistics Canada. As well,
they fund some policy research extramurally.
Senator Cohen: My question is about the Centres of
Excellence for Women's Health.
Ms Elmslie: I knew you would ask me about that.
Senator Cohen: The six years is finished for funding, and I am
interested and concerned as to what the future will be for these centres.
Ms Elmslie: Yes, and I will undertake to provide with you that
information. I do not know the definitive decision on that at this
time, but the Women's Health Bureau in the department will be
my first call when I get back. I will ensure that you get that
Senator Cohen: Thank you.
Senator Robertson: Is your department or division involved in
planning or developing preventive processes and education
material for sustainable longevity?
Ms Elmslie: Yes.
Senator Robertson: If you are, and if you have any data on
that, could we have it.
Ms Elmslie: Yes. The Population and Public Health Branch of
the department, in conjunction with key partners across the
country, is involved in a number of prevention strategies.
The Chairman: In partial response to Senator Cohen's
question, the Institute for Women's Health is appearing here on
I want to understand the decision-making system. Suppose that
a new drug or procedure is developed and then the cost-benefit
analysis shows that the drug or procedure is very expensive and
that it only helps one in ten people. Also suppose that the
conclusion is that Canada's publicly funded health care system
will not fund that process. How is that decision made? Who are
the players and what is the process? Does it mean that Canadians
cannot get that service or drug in Canada, even if they agree to
pay for it? I believe the answer to the second question is yes.
Senator Morin: If it is one death out of ten, who will turn that
The Chairman: I am happy to keep lowering the odds until I
get to the point where someone says that from a cost effectiveness
standpoint it does not work. I come at this from the standpoint of
a mathematician. The reality is that those decisions implicitly put
a value on human life. In the way in which we structure medical
care in this country, we have always ducked the central issue,
which is that we make decisions that absolutely place a value on
human life by virtue of what we decide not to do. I have never
been able to understand who makes those calls. I would like to
understand as well the criteria by which they are made. Also, is it
true that, if that decision is made, people with money are
prevented from buying that service as well?
Ms Elmslie: Your question is outside my area of expertise. I
am not trying to duck it.
The Chairman: You happen to be the victim of the department
who is here today, so we can send you back to get the answer.
Ms Elmslie: That is right.
The Chairman: The question is a crucial one, with regard to
whether certain things will be provided out of public funds. If so,
are they therefore to be prevented from being purchased out of
Senator Morin: First, this decision is never made federally.
The Chairman: It is exclusively provincial?
Senator Morin: Yes, it is exclusively provincial. Second, it is
never made officially in an open way.
The Chairman: Of course, because no one wants to accept the
responsibility for having made the decision.
Senator Morin: They will strike a committee and they will delay. Senator Keon implants artificial hearts that
cost $85,000. Who will say that he should not implant them?
The Chairman: I agree with you that it is deliberately
obfuscated so that no one has the responsibility for making the
decision. I assumed that. Nevertheless, it does seem to me, since
there is an implicit valuation done in this process, that it would be
useful for me to understand how it is done.
Thank you very much for being the victim of our questions.
Ms Elmslie: It was my pleasure. I have some homework to do
and I will be pleased to do that for you.
The Chairman: Senators, our last witness today is Scott
It is not only at Senator Fairbairn's pleading that we have asked
Mr. Murray to talk about the impact of literacy on health; we
want to explore factors that impact on the cost of the health care
system that one does not normally think of as being a health care
Please proceed, Mr. Murray.
Mr. T. Scott Murray, Director General, Institutions and
Social Statistics Branch, Statistics Canada: Thank you for the
invitation to appear before you. By way of introduction, I will say
that I am focusing on the health of older Canadians, but what I
say applies to the health of the rest of Canadians. The basic thesis
is that the literacy skill of Canadians will act as a retardant on the
speed and the equity of Canadians to absorb all of the interesting
things that the health research system is going to turn out. The
context within which this takes place is that individual behaviour
is the biggest agent of social change. It is also, from a government
point of view, the cheapest one, so we should be concerned about
literacy as a retardant.
Senator Fairbairn mentioned that 42 per cent of adult
Canadians do not possess literacy skills that allow them to deal
with everyday reading tasks, including health reading tasks, and
that goes well beyond decoding the printed word. It means using
the printed word to accomplish the tasks that face us.
The population is getting older, and this is where we get into
the dynamics of literacy. Canada is rather unique in the fact that,
at about age 45, we see a rapid deterioration in skill that, even
when adjusted by educational attainment, does not go away. There
is something in the way that we have conceived Canadian
economy and society that causes people to lose their skill in
mid-life rather than in late life, as is the case in Sweden, for
The structure of the Canadian population is going to be dictated
by a number of demographic trends that I understand you have
already heard of, one being immigration. Over half of the
population growth will come from people outside of Canada,
many of whom are not perfectly fluent in our official languages
and are not able to use literacy to deal with everyday demands.
The most troubling aspect is illustrated on the slide entitled
"Forecast Share of Literacy." We have taken the current
relationship of literacy to education levels, immigration and age
and forecast the proportions of the adult population that will be at
The Chairman: Just to clarify, am I correct that on the literacy
level scale 1 is low and 5 is high?
Mr. Scott: That is right. About 5 per cent of the adult population is in levels 4 and 5; 40 per cent is
in levels 1 and 2, which is the level that is determined to have
problems dealing with the economic and social demands that are
implied in everyday reading.
From this graph, you can see that the proportions stay roughly
the same, despite increasing education, because the gains from
education are being absorbed by the losses associated with aging,
at least in Canada. Therefore, a large fraction of the population
will, in the absence of any extraordinarily large investment,
remain with the same skill levels.
It is no surprise that health is very related to education level
and, by extension, to literacy. I have used as an organizing
framework Health Canada's own nine determinants of health. I
will go very quickly through how literacy relates to each of those
The first one is income and social status. Research sponsored
by HRDC and Statistics Canada and done by UBC shows that
over half of the difference in wages paid in the Canadian
economy are attributable to differences in literacy. This is an
astounding impact and points to the importance of literacy to both
the economic and physical health of Canadians.
The Chairman: Since education and income correlate so
closely, is it reasonable to assume that what really drives that is
income and not education?
Mr. Scott: No, it is a combination of the two.
The Chairman: In other words, if you were uneducated but
rich that would not help you as much as being educated but not as
Mr. Scott: That is right.
Senator Morin: Education is more important than income.
The Chairman: I thought income was more important than
Mr. Scott: Income is the product of having access to the labour
market and having access to a good job in the labour market.
When you look at what determines getting access to fulltime
employment and higher wages, literacy explains about half of
that. It is a fundamental underlying determinant. There is an
economic price to pay for people without literacy, and their social
status is reduced.
Fortunately, in Canada, we have a transfer and tax system that
attenuates many of those differences, so it is somewhat adjusted.
If we look at the literacy levels of recent graduates from the
Canadian education system, we see big differences in literacy
outcomes from province to province. The differences are driven
mostly by what happens to children from disadvantaged backgrounds. The effects of literacy are
intergenerational. About 15 per cent of the literacy-skill distribution in the current
population can be related to the literacy skill and educational
credentials of their parents.
The second determinant is social support networks. Literacy
plays a strong role in this area, but its effects are somewhat
second hand. We have a number of social trends that result in
people spending more of their life with fewer social supports.
More people are living alone, particularly at an older age. More
people are retiring earlier. They tend to be self-employed to a
much greater extent. Hence, they have impoverished social
networks and no one they can depend on for needs they cannot
meet themselves. Robert Putnam of Harvard University refers to
this phenomenon as "bowling alone" and attributes it to a decline
in social cohesion.
If we turn to the subject of demand, there is a slide that shows
that seniors, particularly at level 1 of literacy, require assistance in
a broad number of everyday activities, many of which relate to
making health choices and acquiring information related to
Canadians have a relatively high level of education, both in
terms of the stock of educational attainment in the country and in
the current flow coming out of the educational system. It should
have positive effects on health, but we do have this phenomenon
where those educational investments seem to evaporate and we do
not understand the social and economic processes very well.
There is a strong correlation between people who rate their
health as fair or poor and lower educational levels.
I shall now turn to the fourth determinant, employment and
working conditions. Literacy acts as a determining factor that
selects you into the labour market and determines your income.
People with lower skills are selected into occupations that have
lower social status. They are paid less and at far more risk from a
health point of view, with much higher rates of accident and
exposure to occupational hazards. Lower levels of literacy greatly
enhance probability of exposure to unemployment, particularly in
countries like Canada that have open labour markets, where it is
easy to lay people off.
If we turn to the subject of physical environment, literacy levels
also play a role here. People with lower incomes tend to be
geographically segregated in neighbourhoods that tend to be less
desirable and, as such, are exposed to more air- and water-quality
issues as well as problems associated with density in urban
environments. That not only applies to Canada, but also to places
like Poland, where the World Bank has used our literacy data to
show that there are community effects where poverty and
unemployment act in a negative way, synergistically, to make
things worse overall.
The sixth determinant is biology and genetic endowment. We
have not found any relationship of literacy in this regard, but
perhaps our colleagues in the health research areas will find one.
The most important area where literacy plays an key role is in
the issue of conveying health information to Canadians. Literacy
enables people to acquire information on their own. We think that
a significant fraction of the Canadian population do not have the
skills to do that reliably. Demands for reading instructions on
medicine bottles are very high, with over 60 per cent of seniors
doing that kind of task on a daily basis.
There was a presumption that the Internet and health
information on the Internet would be a panacea to save us all.
Over 50 per cent of Canadian homes now have access to home
computers. This figure differs from province to province, so there
is a regional equity issue. However, the utilization of computers in
older age groups, 55 to 64, and 65 and over, is very low at
present. That raises a problem of whether, even if you build it,
they will be able to come.
With respect to the impact on the health of older Canadians,
people with limited literacy, according to information published
by the Ontario Public Health Association, tend to smoke more,
have poorer nutrition, are less likely to engage in physical activity,
use seatbelts infrequently, do not do breast self-examinations,
drink too much coffee and are less likely to have a fire
extinguisher or smoke detector. We are dealing with a group that
has, of their own volition, made unhealthy choices or find
themselves in circumstances where unhealthy choices are forced
In regard to healthy child development, about 15 per cent of
today's literacy is determined by the previous generation's
literacy. Thus, there is a vector for intergenerational transmission of inappropriate health
behaviours. HRDC is
spending a significant amount of time thinking about literacy
strategies that focus on both generations at the same time as a way
of trying to reduce this intergenerational effect.
Health services involve educational programs delivered by a
variety of modes but are increasingly reliant on the Internet as a
delivering mechanism. The basic summary is that large fractions
of the Canadian population do not have the literacy skills to deal
with the kind of information that will be provided on those
systems. One must then think about several things to get around
those problems. Statistics Canada is not in the business of
providing those kinds of solutions, but I can give you three
First, we recommend using the same technology used to
determine what makes adult reading tasks difficult to very
carefully analyze the level of difficulty of material that is put in
the public domain by our health agencies and providers. We can
explain 85 per cent of difficulty and so you could reverse engineer
the information to make it more accessible.
Second, we recommend using the power of the Internet to
provide alternate means of access, the sort of things that Industry
Canada is doing to make Web information accessible to disabled
Canadians and Canadians with low levels of literacy.
Finally, we recommend programs, albeit expensive ones, to
increase literacy levels in the current generation coming out of
school and in the total population.
Making those investments, given the relationship to individual
economic success, one could expect to see both an increase in
economic output and a decrease in health expenditures at the
The Chairman: Right now in this country, health care
expenditures are assumed to be things spent on physicians, drugs
and hospitals and so on. You spoke about potential economic
output because people would be more educated. We are interested
on the impact on health care costs.
Is it possible to do a calculation, however crude, that would in
some sense indicate that "X" amount invested in literacy over a
period of time would ultimately induce the following savings into
the health care system? Where my mind going is to ask if we can
encourage expenditures in other areas on the grounds of what they
would do to help control health care costs in areas not now
typically thought of as health care.
Mr. Murray: Yes and no.
The Chairman: You are a statistician, not an economist.
Mr. Murray: It depends on whether you want to, as my boss
says, be close enough for government work. The technical answer
is that there is not a database that puts health outcomes and
literacy on the same people to make those micro-linkages
longitudinally to establish cause and effect that would let you do
that kind of calculus.
That being said, there are enough second-order things that
show the relative relationships between those variables that you
could come up with a good-enough-for-government-work kind of
calculus that would, I think, come up with very positive health
reductions on top of the economic ones, which would be strong in
and of themselves.
The Chairman: I do not know whether you are the appropriate
person to say this to, but can you do that for us? I am happy
enough to have it close enough for government work.
Mr. Murray: There is a group at Statistics Canada that does
this kind of modelling. They are just about to publish a paper on
smoking and its contribution to average years of lifespan, and of
disability- and disease-free lifespan. It is a short step from that
kind of a modelling, by adding numbers to it, to come up with a
first order of proximation of cost and benefit.
We are considering doing the same thing for basic literacy
investments where, because we can attach economic costs to
various literacy levels, we can come up with a cost-benefit
The Chairman: That would be helpful to us. I do not know if I
am looking at you or Senator Fairbairn. If there is anything this
committee can do to get that project moved up the working list of
Statistics Canada, I would be happy to write a letter or phone
someone. Maybe you and Senator Fairbairn can talk about it. I
hope it can be done before we finish this study, before the end of
this year. This is a great illustrative example. One can look at
other things, but this is the perfect illustrative example. To the
extent that we can get some ballpark quantification, that would be
Senator Fairbairn, do you want to comment on that as well?
Senator Fairbairn: I would certainly be glad to talk with
Mr. Murray to see if we could propel something.
The Chairman: My objective is to try to get government to
understand that if health care cost is your problem, to entirely
focus on a narrow definition of areas of spending is not the way to
solve it. You may be able to help control health care costs by
doing something that is not naturally thought of as a health care
expenditure. That is what I am thinking.
Senator Fairbairn: The only thing I would like to find out, and
you could let us know in writing if there are any other thoughts, is
related to the statistic that you show that in Canada, for some
reason, despite our education system, whatever its limitations,
being relatively good, we start dropping off at age 45 in
comparison to other countries such as Sweden. What are other
countries doing, and what are the influences that we are aware of
that make that happen in Canada?
Mr. Murray: We are going into the field with a second literacy
assessment internationally in 2002. One of its prime objectives is
to answer that question. There are two hypotheses. One
hypothesis is that Canada suffers a deficit in the factors that
support literacy in adult life. Those determinants have to do with
the kinds of jobs we have and the kinds of reading demands that
are placed on workers in those jobs.
Swedes on the job read twice as much as Canadians do. This
has an impact on maintaining their literacy level. They also tend
to read more than Canadians at home. That has a positive effect.
They participate in adult education at a level that is twice the
average for Canadians, and they do so throughout their working
life, whereas we see the same kind of reduction in adult education
participation in midlife as we see in literacy levels in Canada.
The Chairman: We know from the old 60-year-old Swede
advertisements that they are also in better shape than we are.
Mr. Murray: Not only are they skiing better, they are reading
a book at the same time.
The second hypothesis is that the younger generations replacing
the older ones will bring with them better behaviours. They in fact
will create more literacy-rich jobs and we will not see this pattern
of skill loss continue. For now, it is an open question.
Senator Graham: Thank you, Mr. Murray, for a very
I am compelled to ask a question related to slide 9 and,
generally speaking, to all of us. You talk about the relationship
between the availability of preventive and primary care services
and improved health, and this is under the heading "Literacy's
Impact on The Health of Older Canadians." You use the example
of Well Baby and immunization clinics.
This document deals with older people and their relationship to
the relative health of Canadians. I wonder, Mr. Chairman and
Senator Fairbairn, under the general heading of literacy and the
health of Canadians, whether we should consider at some point
the importance of literacy and the relationship between literacy
and health at a very early age, and the importance of reading and
encouraging our children to read. The formative years are,
comparatively speaking, the most important years of a person's
life, whether the years are between the age of two and five, or
three and six, or whatever. While this is a most interesting
document and very important to us, at some point we will have to
focus on the beginnings.
The Chairman: By the way, that was the real purpose of my
question. In the sense, you hit it exactly. There are two issues.
First, there are the people who are now illiterate or not sufficiently
literate. Second, how do you stop the next generation from
following the curves that Mr. Murray put on the table?
Mr. Murray: We do have a series of surveys. We have been
approaching this in exactly that way. There is something called
the National Longitudinal Survey of Children and Youth that
looks at kids from zero to 12, originally. We have been following
them longitudinally. It includes direct measures, tests of their
reading ability, and relates it to a variety of social, economic and
Senator Graham: And habits.
Mr. Murray: And habits, including interaction with their parents and the parents' reading
behaviours. That is
complemented by a study launched in the last year that looks at a
big sample of 15-year-olds and tests their literacy in a very
elegant way, using the same kinds of tests we have used to test the
entire adult population's skill level. We will follow those kids and
see how much of their skill level can be related to their social and
economic characteristics, looking backwards, and how much that
skill conditions their access to the post-secondary system and
eventually into the labour market, whenever they happen to get
there, whether they go directly from high school or after some
post-secondary career. That data system is happily mostly in place
to explore the issues that you suggest.
The problem is that the skill demands in the labour market are
going up so quickly and we have so few children relatively as a
proportion of the population that there is an economic worry that
there are not enough kids to fix the problem fast enough. The
solution may lie in doing something with adults.
Senator Fairbairn: If I may, just for the interest of senators,
this issue of early childhood has been directed to us from the
ground rather than from the top. In the last few years, family
literacy has probably become, in terms of those on the ground
who are involved in this issue, the hottest button of any in
Canada. We heard Dr. Mustard a while ago, and his paper of
several years ago startled many people in this country. He showed
not only that children were able to be imprinted with an interest
and a love and an ability to learn from about 18 months on
neurologically, but that if they got to the age of five or six and
none of the stimuli had been available some of those windows
would close and would never reopen. This is a very big
consideration. When you hear about early childhood enhance ment, that is part of it.
The Chairman: Thank you, Mr. Murray, for attending. I loved
having another mathematician before the committee.
Senators, I have three quick announcements. Some of the
committee members had to leave, so I will also send these to you
in memo form.
Particularly for all of those from the Atlantic, we are working
on the changes in the EI bill aimed at seasonal workers next
Wednesday. The minister will be here, along with several other
Thursday, we are considering the health information highway.
You have received a memo that we circulated today but will send
out again and follow up with everyone. The memo asked to
confirm August 22 and 23 as the two days we would meet in the
summer to finalize the fourth report. It will have to be in the last
several weeks in August. We need two consecutive days. Please
let us know if those dates do not work. I will have the clerk
follow up on that with you, because I really do want to lock that
Finally, and I will send this out in a memo as well, you will
recall that we agreed to meet on Mondays to do the international
teleconferences, because it was the only way to do it, and we
agreed on the four Mondays. They are in the schedule sent out to
you. I should inform you that on those four Mondays we will do
Sweden, the Netherlands, Britain and Germany. We will do the
U.S. in a regular time slot because we are in the same time zone.
We will have to do one Tuesday night, because that is the only
way to do Australia.
When I chaired the Banking, Trade and Commerce Committee,
we did a two-hour videoconference with the governor of the
central bank of New Zealand. We found that the only way to
make it work with his schedule was to have us start about seven at
night, which is eight in the morning his time. Therefore, we will
add a Tuesday night in late May or early June. Between now and
the middle of June, we will have one session devoted to each of
six different countries.
I am setting all of that out just so you know what we have
ahead of us. I would hope that we have a full agenda, particularly
for all of us from the east, for next Wednesday.